The study is an audit of a major change in medical curriculum of Year IV and V MBBS. The above mentioned modification of curriculum and clerkship duration was a new experience for both students and faculty. With an increase in number of examining subjects in year IV and an overall reduction in exposure of teaching for paeds and gynae obs clerkships to 2 years, there was a definite stress of giving and taking the exam for students and faculty. Various students respond to and handle stresses differently. Literature describes the main sources of stress for medical students as time pressure, heavy workload, fear of failure, and examination frequency. Ragab etal report overall prevalence of stress in medical students 31.7% (p < 0.05). 13,14
Literature review reveals varying observations with modified span of clerkships in various subjects. Julie et al reported that curriculum change could produce improved performance, despite a reduction in psychiatry clerkship length from 8 to 4 weeks. 15 Edward et al describe similar results as ours. They reported that decreasing the duration of the obstetrics-gynaecology medical student clerkship from 8 to 6 weeks, resulted in lower subject examination scores. 16 Whereas Lindsay et al found no significant difference in clinical scores on shortening medical clerkship in year 3 students.17
In Gynae & Obs OSCE exam, students showed better mean scores with 2 years of teaching (141.59 ± 15.59) vs. (146.66 ± 11.38) for class with 3 years of teaching (p-value 0.015) Table I. Student Patient interaction was maximized in almost all clerkships with this change. We got comparable results in gynae and obs theory. ENT discipline having the same status, shows improvement in OSCE component result (p value 0.00). Probably students were able to retain the clinical part better in 2 years of teaching as clinical exposure was maximized during these years. Another reason could be better performance in subject of interest .18 Mean scores of theory in ENT and ophthalmology disciplines almost remain the same. One of the reason could be faculty bias in making relatively easy paper and lenient marking considering change in duration of curriculum delivery.
There was no change in Ophthalmology results with 3 or 4 subjects in professional exam. Probably the reason could be that this clerkship had no change of duration, just a subject was added that year. High scorers were almost the same in both classes except for paediatrics theory exam where students could not score > 80%. (p value 0.00). On the contrary ENT OSCE showed 13 students with > 80% score (p value 0.00) which could be due to subject interest and effective teaching;
Regarding Paediatrics, the results were comparable for both classes in OSCE exam (p value 0.192) whereas, in theory section students with 2 years teaching scored less than the class with 3 years of teaching (p value 0.000). This situation was already expected in this scenario. Modifications in curriculum involving changes in one whole year of teaching, the students ‘performance declines.19 Faculty was anticipating the stress of students so they were committed to modify teaching strategy in order to facilitate students for this transition time. Anticipating the same situation, we have already allocated double time (8 weeks) to the clerkship as compared to previous years in year IV (4 weeks). Many of the changes to individual clerkships involved rearranging student clinical time to maximize patient volumes and streamline student experience in different patient care settings. We cannot expect each student of class to retain the lecture 100 percent.20 Self-study habits, revision of subject and clinical application of knowledge varies from student to student. 21,22These changes may have improved clerkship efficiency as it relates to student-patient interactions despite a decrease in rotation length.
Moreover, students’ maturity, reasoning and understanding with one whole year of rotations in various disciplines increases his/her ability to understand and relate things. This cannot be bypassed. Pediatric Theory is very much like medicine. These have many things overlapping. The Must Know component in paediatrics is quite a lot which cannot be shortened to produce safe doctors. OSCE performance of students was quite well as this does not require much theory to test. Students get generally good grip for hands on component in short time even better if they are keen. One of the reason could be that they were given extra classes /sessions for practice of clinical skills. Moreover, many factors are responsible for students’ academic performance like Al Shawwa et al reported that excellent medical students have many different characteristics as social networking for lesser periods of time (p value < 0.01) and they have strong motivation and study enjoyment.23Mean scores of class with 3 years teaching were better in Paeds theory (71.66 ± 7.88) as compared to 2 years teaching (65.01 ± 6.61) with p-value = 0.000. The upper range for scores was also better for the same group of students i.e. 87.67 vs. 78.09. Lindsey et al report in contrast to our observation. They did not find any statistically significant difference (p value < 0.322) between groups with traditional and shortened teaching time in year 3 medical school step 1 exams in paediatrics. 19
If we look into the failure /supplementaries of Gynae and paediatrics we find the same trend. In paediatrics we got 5 supplementaries in theory exam which are more than in the other cohort (p value 0.00). Paediatric OSCE result also showed 2 supplementaries as compared to none in the other class. We can observe that 3 years teaching has better outcome in terms of pass rates. Family medicine discipline also entertains paediatrics in its scope. We look forward to addressing important Pediatric issues in family medicine in final year of their teaching. Recently the University of Michigan published a study of their clinical clerkship curriculum changes which showed a 25% decrease in clerkship length resulted in no significant student performance differences .24 Some studies show no difference in student satisfaction with shorter curricula or even better evaluation scores for shortened curricula. 4
Shortening the clerkship time may have served as an impetus for clerkship directors to ensure the rotation was highly organized and to maximize student time with patients and supervising faculty. The lack of cohort differences in the OSCE performance may be due to the focus of the OSCE on core clinical conditions, our institution’s robust pre-clerkship clinical skills course, or student time spent immersed in clinical patient care. Some factors may be the variety of physicians with whom students spend time and the variability in training, practice, and teaching patterns. 25 Another factor is that students’ didactic exposure in the third and fourth years is often dependent on the educational sessions and patient cases available at their rotation site.
Our study has certain limitations. We compared only 1 year results and did not compared it with results of students of final year appearing only for 3 years. We did not enquire about student’s perspective about change in clerkship plan and subjects of interests, so we recommend that further studies should be conducted taking in view of student’s perspective. We analysed students’ performance only but did not accounted for student’s perspective about shorter duration of clerkship and subjects of interests.
The main strength of our study is that it’s the first one from this region depicting effect of shortened clerkship duration on student performance. This will be a guide for improving and designing curriculum in future.